Monitor Patient Outcomes

You already record patient outcomes, such as blood pressure or weight. If you are just starting to treat people with medications for OUD, you may be interested in adding one or more of the outcomes listed below, under Treatment Retention. If your practice offers more comprehensive, whole-person services for OUD, you may choose to collect more extensive data including standardized measures.

Common patient outcomes and standardized measures for OUD treatment are described below. These include treatment retention, abstinence or reduced substance use, progress toward the patient's treatment goals, and indicators of mental health and quality of life.

Treatment Retention. Treatment retention is one of the most important outcomes to track. Longer treatment with medications for OUD is associated with significantly better outcomes across a range of life areas, such as:

• Decreased opioid-related overdoses,^1,2emergency department visits, and mortality;³
• Reduced polysubstance use;⁴
• Increased abstinence;^1,5,6
• Improved overall health;⁶
• Decreased arrests;⁷
• Improved employment;⁸
• Family restoration;⁹
• Decreased legal system involvement;⁸ and
• Improved quality of life.¹⁰

There is a lack of consensus in the field regarding minimum treatment duration, with some suggesting 12 months¹¹ and others reporting better results for even longer periods of treatment.¹² However, about half of those who discontinue treatment do so within the first 30 days of starting treatment.^13-16 As addiction is a complex and recurring disorder, a high proportion of people who discontinue treatment re-enter treatment at a later date.¹⁷

Treatment retention is a simple concept, but it can be confusing to measure since both practice admission and discharge/cessation can be ambiguous. A simple option is to:

• Admission can be defined as the first receipt of (or prescription for) medication for OUD from your practice. Ideally, the interval between first contact and medication is as brief as possible^18,19
• Discharge can be defined as the last patient contact related to treating their OUD. Depending on your practice's approach to treatment, other outcomes may be more important to track. A common convention is to count a 30-day interruption of MOUD as a discharge/cessation, even if the patient later re-enters treatment.

Treatment retention rates are typically reported for a specified period. The most critical retention rates to monitor are 30 days and 1 year. If possible, consider measuring 30-day, 60-day, 90-day, 6-month, and 1-year retention rates.

To calculate retention rates — or the percentage of patients who stay in treatment over a specific timeframe — you can use the following formula:²⁰

Where:

• E = Total number of patients who remain in treatment at the end of the period
• N = Number of new patients admitted during the period
• S = Number of patients in treatment at the beginning of the period

For example, if you started with 100 patients (S), ended with 100 patients (E), and gained 10 new patients (N), the retention rate would be:

This metric allows you to determine mean treatment retention over a specific timeframe. Retention rates reflect the effectiveness of treatment programs by indicating both care stability and the likelihood of continued patient participation, which are essential for assessing care quality and long-term recovery outcomes.^21,22

To truly measure therapeutic success, however, consider treatment retention as well as other clinical and quality of life outcome measures.²³

Continued Substance Use: Continuing to use drugs, such as opioids and other substances, or a recurrence of use is an important gauge of patient progress. Patients who use illicit substances are not "failing" treatment; they may just need changes to their treatment plan. It is also possible that patients who continue to use may need additional services, such as more visits or counseling, or a higher level of care.²⁴ Either way, continued substance use is not a reason to discontinue providing medications for OUD because the primary goal of MOUD is to keep people alive by reducing risk of overdose.²⁵

At each visit, check for substance use, including alcohol and nicotine. A urine drug screen can be more accurate than patient self-report, as some patients do not want to disappoint their provider by disclosing use.²⁶ Your nonjudgemental manner can help strengthen communication with your patients. Learn more in Challenging Patient Behaviors or Concerns and Prevention and Response to Recurrence of Use.

Note. The rest of this module may be more practical for larger practices that are able to provide more comprehensive whole-person treatment of people with OUD, or for practices that conduct clinical research.

Patients' Treatment Goals: Progress toward patients' personal goals are useful to monitor, although they may be more subjective or harder to measure. Examples of measurable goals are:

• Attendance at appointments: Missed appointments may indicate the patient is struggling, using opioids or other substances, or facing logistical issues, such as lack of childcare or transportation. Telehealth may be an effective workaround for some logistical issues, but it may not be feasible or available due to Internet access, privacy, etc. Take a person-centered approach to identify the issues and seek solutions.
• Patient's priority goal(s): It is important for patients to set goals for themselves such as reuniting with children or family, stable housing, or enrollment or retention in a job or school. These goals may be the most motivating and rewarding to patients, which may help them stay in treatment longer.²⁷
• External supports: Practices with a more comprehensive array of services for people with OUD can also measure engagement with behavioral health services or external recovery supports.

Mental Health Symptoms: As relevant for individual patients, monitor symptoms of comorbid depression, PTSD, or anxiety symptoms, which can affect patients' management of OUD and their quality of life. (Discussed in Counseling and Psychosocial Supports.) Where feasible, consider using validated²⁸ tools to measure and track symptoms of:

• Depression: Data Element: Patient Health Questionnaire 9 item (PHQ-9) total score [Reported] (2001) — includes a suicide risk screening item and or 2-item version: Form: Patient Health Questionnaire-2 (PHQ-2) (2015) without the suicide risk screening item;
• Anxiety: Generalized Anxiety Disorder 2-item (GAD-2) - Mental Health Screening - National HIV Curriculum (n.d.) — GAD-7 and PHQ available from the same website; and
• Post-Traumatic Stress Disorder (PTSD): (PCL-5) PTSD Checklist for DSM5.pdf (PDF - 65 KB) (2013)²⁹ — 20-item screener for PTSD that can be used to track PTSD symptoms over time. This scoring template was posted by Oregon Health and Science University (OHSU). For scoring, the PTSD Checklist for DSM-5 (PCL-5) — Scoring Guide (PDF - 662 KB) is posted by the Canadian ADHD Resource Alliance (CADDRA).

Life Improvement. You can monitor life improvement relative to addictions treatment using tools such as:

• The 4-item Treatment Effectiveness Assessment (TEA) asks patients to rate their substance use, health, lifestyle, and community along a 10-point scale;
• The Short Inventory of Problems Revised (SIP-R) (PDF - 26 KB) has 17 items that assess a patient's physical, social, intrapersonal, interpersonal, and impulse control issues; and
• Brief Addiction Monitor (BAM) Intensive Outpatient (IOP) Version (PDF - 388 KB) includes 17 questions about physical health, sleep, mood, substance use, spirituality, employment, finances, social and familial support, and recovery goals.

Recovery capital refers to the probability of a patient having a successful recovery based on the breadth of recovery supports they receive and the extent to which their recovery needs are met. For more information on this construct see: The science of recovery capital: Where do we go from here? | PMC. This article describes two measures of recovery capital:

• The Brief Assessment of Recovery Capital-10 (BARC-10) — 10 items measuring physical dependence, emotional dependence, and loss of control to identify what additional supports the patient needs; and
• The Recovery Capital (REC-CAP) — a comprehensive assessment of a patient's recovery.

General Functioning and Quality of Life. A patient's quality of life, life satisfaction, and general functioning are important to recovery. Improvements in these can be tracked and monitored to assess the patient's progress over time. Several instruments assess quality of life, but none specifically address those with OUD. The instruments vary widely in terms of content and administrator or respondent burden. Examples include:

• WHOQOL: Measuring Quality of Life | The World Health Organization — general quality of life measure in multiple languages;
• Dartmouth COOP Charts — general functioning primary care settings: (may require a fee); and
• Additional measures to assess well-being and life satisfaction, as well as physical, mental, and social health are linked in the HealthMeasures database.

Note. This section may be more practical for larger practices that provide more comprehensive, whole-person treatment for OUD or for practices that conduct clinical research.

There is a good chance that you already use some form of electronic system for patient data, whether it is an EHR, patient registry, or another type of database. Most office-based providers use an EHR system (88.2% in 2021)³⁰ which facilitates monitoring of patient care and coordinating care with other providers.

Many newer EHR systems have the capacity to aggregate multiple patient records and analyze patient outcomes. The same is true for many patient registries and other datasets.

Even if your practice does not use an electronic system that allows for simple aggregation of patient data, it may be possible to:

• Create a basic spreadsheet that includes the data elements you wish to monitor;
• Access patient data in electronic form that can be downloaded into a spreadsheet (e.g., Excel) for analysis. This data may be maintained by office or paraprofessional staff. For example, your practice may maintain a billing dataset that includes diagnosis, dates of service, service provided, and type of payor; and
• Private centers may offer tracking systems and courses for free or for a fee. For example, the AIMS Center of the University of Washington has developed a Care Management Tracking System and other resources for registries to support collaborative healthcare.

Systematically tracking quality measures (also known as "performance measures") will help identify areas in need of improvement; set measurable goals for change; and evaluate the effectiveness of a new policy, process, or procedure.¹ Measures can be used for quality improvement initiatives, benchmarking against other providers or organizations, and accountability.² Performance measures can also be similar, if not the same, as those used for Tracking Patient Outcomes and simply used for additional purposes.

Consider the practice's strengths and weaknesses, and identify areas for improvement such as issues related to access, implementation, and outcomes:

Access: Patients may experience gaps in service coverage or other barriers to care, as evidenced by long waits for care, high no-show rates or loss to follow-up. Consider tracking measures related to the number of patients on a waiting list, time elapsed between first contact and patient's first treatment services, time elapsed between follow-up visits, and similar measures.

Implementation: Practices may need to improve their processes to identify patients with OUD, attitudes toward those with OUD or other SUDs, capacity to serve patients with OUD, or confidence in team function and shared workflows. Related performance measures may include:

• Number of providers and staff trained to understand OUD and treatment best practices;
• Number of new patients started on medications for OUD;
• Percentage of patients being prescribed medications for OUD among those with an OUD;
• Number of patients served by the practice;
• Proportion of eligible providers who are willing to prescribe medications for OUD;
• Proportion of providers actively prescribing medications for OUD;
• Proportion of providers prescribing medications for OUD to at least XX patients, where XX can be any minimum number of patients of interest; and
• Average caseload (of patients with OUD) per prescriber.

Outcomes: Additional areas for improvement related to the impact of the MOUD practice on patient outcomes include reduction in opioid and other substance use, retention in treatment, patient functioning, follow-up and engagement with external referrals, overdose rates, utilization of hospital services, impact of co-occurring conditions, and other health outcomes among more complex patients. To measure progress in these areas, providers may consider monitoring:

• Retention rates (30-day, 60-day, 90-day, 6-month, 1 year);
• Continuous MOUD refills;
• Health-related quality of life scores;
• Functional outcomes;
• Patient satisfaction;
• Form: Patient Health Questionnaire-2 (PHQ-2) scores;
• Pain, Enjoyment, and General Activity (PEG) scores (among patients with chronic pain);
• Participation in counseling or other recovery supports; and
• Mortality rates.

The measures used will vary based on the practice's goals, model, and capacity for analysis. When selecting measures, consider the time and resources needed to collect and analyze these data. It is best to start by selecting one or more measures that are both important to the practice or patient population and reasonable to measure with existing resources.³

How will data be collected? Determine the intervals at which data will be collected for each measure they focus on at any given time. When choosing quality measures, consider the burden on providers, staff, and patients to collect the data as well as how data will be stored (e.g., electronic health record system, care registry, separate database, or spreadsheet). Use data from existing sources whenever possible. Note that some of the phone- or computer-based apps designed to provide treatment and support recovery for people with OUD or other SUDs include patient reported outcome measures that can be shared with the provider with patient consent. The apps can thus provide a low-burden approach to obtaining helpful outcome data.

How will data be analyzed and reported? Decide how frequently to conduct data analysis and summarize the results. Consider whether performance indicators will be reported across the entire practice that treats OUD, by care team, or specifically by provider.

When undertaking quality improvement initiatives, consider any barriers to change in the practice, such as internal resistance due to negative attitudes, a lack of understanding, or competing priorities. The Network for the Improvement of Addiction Treatment (NIATx) recommends picking a powerful change leader with the respect, authority, and time to help with these quality improvement activities.⁴ Also, involving stakeholders from across the practice in the planning and implementation of any changes will provide unique insight from members with different roles and will encourage staff buy-in.

Some practices may also need additional external support from other individuals or organizations to help with quality improvement efforts, such as⁵:

• Data feedback and benchmarking: Offers feedback on key quality indicators and allows practices to compare performance with other practices and providers. It can identify areas for improvement and provide motivation to change.
• Practice facilitation or practice coaching: Helps build the practice's skills and internal capacity for quality improvement through sharing of tools, resources, and expertise.
• Expert consultation: Encourages adoption of best practices by sharing knowledge and experience.
• Learning collaboratives: Creates a community to collaborate among peers, share lessons learned, and promote a culture of quality improvement.

These external supports may come from a variety of sources such as quality improvement organizations, practice-based research networks, professional organizations, and public or private insurers.⁶ Check for local organizations, state practices, or federally funded initiatives that may be available.

"While all changes do not lead to improvement, all improvements require change. The ability to develop, test, and implement changes is essential for any individual, group, or organization that wants to continuously improve."⁷

Whenever possible, change your practice based on data collected and analyzed by your practice. After selecting an area for improvement, create goals or objectives for the desired changes. These goals should be SMART (S-Specific, M-Measurable, A-Achievable, R-Realistic/Relevant, T-Timely).

Plan-Do-Study-Act (PDSA) Cycles: Changes can be implemented and tested with a process such as the PDSA cycle. PDSA is a series of short, rapid cycles in which changes are tested first on a small scale, adjusted if needed, and then fully implemented when the results indicate significant improvement. This incremental method of implementing and testing changes helps minimize resources invested until a change has demonstrated significant impact. Starting on a small scale also allows practices to make changes in a manner that is less disruptive to clients and staff and less likely to encounter staff resistance.⁸

The stages of a PDSA Cycle are:⁹

• Plan—Identify the purpose and goal of the change. Develop a plan to test the change, including who should be involved and how data will be collected and analyzed.
• Do—Implement the change on a small scale. Collect data and document any problems or unexpected observations.
• Study—Analyze the data and compare the results with your predicted outcome. Summarize and reflect on what you have learned so far.
• Act—Plan for the next steps you will take based on the results of the test. Consider whether the change should be adopted (implement and test on a larger scale), adapted (modify the change and begin a new PDSA cycle), or abandoned (stop testing this change idea).

Lean Management Principles: The focus of lean management principles is eliminating waste and maximizing value to the patient by streamlining processes and workflows. This approach has been used effectively in manufacturing companies for decades, particularly in Japan. Learn more about lean management principles in the Institute for Healthcare Improvement's white paper Going Lean in Health Care.

Communicating the Results: Share successes of quality improvement efforts with providers and staff in your practice. It can create a positive feedback loop in which seeing discernible changes and improvements will help gain staff buy-in for future quality improvement initiatives.